Current Patients
203-453-4344
New Patients
000-000-0000
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Please complete the forms below prior to your first visit.
Dental History
.
Authorizations and Acknowledgements
.
Medical History
How many teeth are you currently missing?
*
0
1
1-3
4 or more
Are you currently wearing a denture?
Yes
No
What implant options interest you the most?
*
Full upper arch of implants
Full lower arch of implants
Full upper and lower arch of implants
Individual or Single Implants
I don’t know, I’ll let the doctor decide
What makes you unhappy about your smile?
Are you in any pain or discomfort?
*
Yes
No
Sometimes
What has kept you from achieving the smile of your dreams?
*
I’m ready!
I don’t have a dentist
I can’t afford it
I’m afraid or I have fear of the dentist
I’m embarrassed
Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?
*
Yes I am!
No I will not need a payment plan
Payment plans are based on credit approval, you may also bring in a co-signer. If you could guess, what is your credit score?
500-550
551-600
601-650
651-700
701+
I don't know my credit score
Based on your score, you may not qualify for financing. Do you have a friend, family member or spouse who will co-sign with you for financing?
Yes
No
Unfortunately, it appears that you will not qualify for financing options for dental implants. Is there another way for you to pay for your perfect smile?
Loan from friends and family
Bank loan
Home equity line of credit
Personal savings
Retirement
Credit Card
No, I don’t have any other way at this time
AT THIS TIME IT DOES NOT APPEAR THAT YOU ARE A CANDIDATE FOR DENTAL IMPLANT FINANCING. HOWEVER, OUR OFFICE COULD CONTACT YOU TO FOLLOW UP. WOULD YOU LIKE US TO CONTACT YOU TO SCHEDULE A VISIT?
Yes, call me ASAP
I'd be interest in a visit sometime in the near future
I’m still thinking about it. Don't contact. me.
How soon would you like to get scheduled?
ASAP
Sometime in the near future
I’m still thinking about it
What is your email address? (Only used to send you useful dental implant information)
*
What is your name? (Only to use in the email and to be polite)
*
First
Last
What is your ZIP Code?
*
What is your phone number? (A treatment coordinator will call you to schedule a visit and answer your questions.)
Patient Information
How many teeth are you currently missing?
*
0
1
1-3
4 or more
Are you currently wearing a denture?
Yes
No
What implant options interest you the most?
*
Full upper arch of implants
Full lower arch of implants
Full upper and lower arch of implants
Individual or Single Implants
I don’t know, I’ll let the doctor decide
What makes you unhappy about your smile?
Are you in any pain or discomfort?
*
Yes
No
Sometimes
What has kept you from achieving the smile of your dreams?
*
I’m ready!
I don’t have a dentist
I can’t afford it
I’m afraid or I have fear of the dentist
I’m embarrassed
Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?
*
Yes I am!
No I will not need a payment plan
Payment plans are based on credit approval, you may also bring in a co-signer. If you could guess, what is your credit score?
500-550
551-600
601-650
651-700
701+
I don't know my credit score
Based on your score, you may not qualify for financing. Do you have a friend, family member or spouse who will co-sign with you for financing?
Yes
No
Unfortunately, it appears that you will not qualify for financing options for dental implants. Is there another way for you to pay for your perfect smile?
Loan from friends and family
Bank loan
Home equity line of credit
Personal savings
Retirement
Credit Card
No, I don’t have any other way at this time
AT THIS TIME IT DOES NOT APPEAR THAT YOU ARE A CANDIDATE FOR DENTAL IMPLANT FINANCING. HOWEVER, OUR OFFICE COULD CONTACT YOU TO FOLLOW UP. WOULD YOU LIKE US TO CONTACT YOU TO SCHEDULE A VISIT?
Yes, call me ASAP
I'd be interest in a visit sometime in the near future
I’m still thinking about it. Don't contact. me.
How soon would you like to get scheduled?
ASAP
Sometime in the near future
I’m still thinking about it
What is your email address? (Only used to send you useful dental implant information)
*
What is your name? (Only to use in the email and to be polite)
*
First
Last
What is your ZIP Code?
*
What is your phone number? (A treatment coordinator will call you to schedule a visit and answer your questions.)
Dental Office
Arpita Patel, BDS, DDS
5 Durham Rd, C3
Guilford, CT 06437
Office Phone
New Patients:
(000) 000-0000
Current Patients and General Office Information:
(203) 453-4344
Office Fax
203-453-6187
Office Hours
Monday: 8:00 AM – 5:00 PM
Tuesday: 8:00 AM – 5:00 PM
Wednesday: 8:00 AM – 5:00 PM
Thursday: 8:00 AM – 5:00 PM
Friday: Closed
Saturday: Closed
Sunday: Closed
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.
The information on this website is for general information purposes only. Nothing on this site should be taken as medical advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute a doctor-patient relationship.
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